VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Great Falls Assisted Living
1121 Reston Avenue
Herndon, VA 20170
(703) 421-0690

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: April 6, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 4/6/21 and concluded on 4/29/21. A complaint was received by the department regarding an allegation in the area of: Resident Care and Related Services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-560-F
Complaint related:	Yes
Description:	Based on documentation and interview, the facility failed to ensure that information be made available only when needed for care of the resident. Evidence: Progress notes for Resident #1 indicate that the resident was transported to the hospital via ambulance on 12/25/20. Facility policy states that a resident summary/transfer referral form, resident data sheet, a functional status form, current MARs (medication administration records), and advanced directives are to be sent with the resident when they are transported. A facility incident report states that an incorrect face sheet was furnished, when Resident #1 was sent to the hospital on 12/25/20. Facility staff reported that Resident #2?s face sheet was furnished instead of Resident #1?s, and that Resident #1?s husband corrected the issue at the hospital. Resident #2 was not hospitalized or transported by emergency medical professionals on 12/25/20. Hospital staff were in receipt of Resident #2?s medical history and diagnoses. Resident #2's face sheet was observed during the inspection, and the face sheet does not include information about the resident's medical history or diagnoses. A page from Resident #2's physical examination, completed in 2017, had been furnished when Resident #1 was transported to the hospital.
Plan of Correction:	Resident #1 and #2's medication orders were reviewed. Both residents were shown to the HWC to ensure knowledge of who the residents were. Director meeting was held by the temporary ED to ensure all protocols and policies are understood. DHW and/or designee will ensure that HWC and licensed staff are aware of the residents that are being transported out on an on-going basis. DHW and/or designee will in-service all licensed nursing staff on the importance of knowing the policy on which information is needed to give to the transportation services when transferring residents to a hospital setting. DHW and/or designee will have random checks on the residents that are transported out to ensure the policy is being followed on proper documentation being given to emergency services personnel. The ED and/or designee will complete random checks as well.
Standard #:	22VAC40-73-650-F
Complaint related:	Yes
Description:	Based on documentation, the facility failed to obtain new orders for all medications and treatments prior to or at the time of the resident's return to the facility, whenever a resident is admitted to a hospital for treatment. The facility shall ensure that the primary physician is aware of all medication orders and has documented any contact with the physician regarding the new orders. Evidence: Progress notes report that Resident #1 was transported to the hospital on 12/25/20 and returned on 12/26/20. The hospital discharge medication list indicated an adjustment to Resident #1's Donepezil, Doxycycline, Levetiracetam, and Vitamin D. Resident #1's MAR does not indicate any changes to the resident's Donepezil, Doxycycline, Levetiracetam, or Vitamin D. No documentation was found in Resident #1's progress notes regarding the changes to her Donepezil, Doxycycline, Levetiracetam, or Vitamin D.
Plan of Correction:	Resident #1's medication orders were reviewed, however they were moved to another community prior to the physician coming in to sign the new orders. DHW and/or designee will audit all current physician orders to ensure that all medication orders are reviewed and appropriate to the orders given. DHW and/or designee will in-service all licensed nursing staff on the physician order process. All residents that are admitted into a hospital for treatment will have orders reviewed upon return to ensure proper physician orders are in place and documented. DHW and/or designee will check all resident's orders once they are back in the community and make physicians aware if need be for any order changes. The ED and/or designee will complete random checks on orders.